Melbourne School of Population and Global Health - Theses
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ItemThe ethical challenges associated with medical internship and residency( 2009)Internship and residency are the first years following graduation from medical school. Interns and residents work in hospitals as the junior members of hierarchical medical teams. To date there has been little systematic philosophical work that focuses specifically on this group. Instead, in ethical discussions, interns and residents tend to be included either with medical students or with their more senior colleagues. In this thesis, I argue that interns and residents differ from both medical students and more experienced doctors in ethically important ways. Their working context requires them to play multiple roles simultaneously, including doctor, subjugate team member, learner, and hospital employee. The demands of these multiple roles create a set of ethical challenges for junior doctors that is unique to their professional stage. Further, the potentially conflicting demands of these multiple roles limit the ways in which junior doctors can act in response to the ethical difficulties that they encounter. I thus propose that the ethical challenges associated with medical internship and residency can be fruitfully understood as role virtue conflicts. Aiming to produce a work of empirically-informed moral philosophy, I investigate junior doctors‟ ethical issues using a combination of literature review, semi-structured interviews, and philosophical analysis. In-depth interviews with fourteen Melbourne-based junior doctors formed a central element of this project, in order to ensure the project‟s focus on pressing practical issues. On the basis of these interviews and my review of research findings about junior doctors across various disciplines, I develop a typology of the kinds of ethical challenges associated with internship and residency. These include being involved in treatment perceived as futile, seniors discouraging disclosure of errors, and reporting unrostered hours. In addition to the typology of ethical issues, I develop and use a role-based framework as a way of analysing the ethical challenges faced by interns and residents. The method of ethical analysis that I propose conceptualises the good junior doctor as good qua four roles, each with a differing set of role virtues. I argue that this role-based framework both reflects and engages with junior doctors‟ specific position of agency and thus captures a fuller range of moral considerations than do other possible modes of analysis.
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ItemOverseas doctors in Australian hospitals: an ethnographic study of how degrees of difference are negotiated in medical practice( 2009)In this thesis I ethnographically examine overseas doctors' negotiations of hospital settings that are similar, yet simultaneously unfamiliar, to those they have previously known. The study foregrounds the social labour involved in moving medical practices from one clinical context to another, a process too often hidden from view in the myth of medical universalism. The stories take place in hospitals on the metropolitan fringes of a large city in Australia. The research assumes that doctors with overseas (i.e. non-Australian/New Zealand) medical qualifications have developed a different set of practices to 'locals' because they have received their education and training in medical places 'elsewhere'. In the thesis, I argue that overseas doctors negotiate these various differences with modes of adjustment. I examine adjustment as an embodied, sensory and situated process that entails constant threading between the overseas doctors' past and the environment they find themselves part of, revealing something of both along the way. The overseas doctors' new environment is one that includes an evolving arrangement of people and paperwork, registration and assessment procedures, and buildings and tools. Whilst adjustment to these human and non-human aspects of a doctor's ecological terrain is an everyday event in medicine, I suggest that it is made more obvious by international migration, by practitioners who do not take their new environments for granted. For overseas doctors, subtle variation can mean an exciting, yet more often unsettling world of difference. This research highlights the contextual nature of medical practice, exploring its embeddedness within a multifarious environment. At the same time, the thesis departs from the majority of literature on overseas doctors, and skilled migrants more generally, that regards their skills as too context specific, thus requiring their integration into a nationally distinct system through the acquisition of nationally distinct practices. With this thesis I contribute an empirically and theoretically rich analysis that provides a more nuanced perspective of this political issue in Australia (and other 'receiving countries'). It is a thesis that will be of interest to migration and organisational researchers, medical educationalists, sociologists and anthropologists of science and medicine, individuals and organisations concerned with the steadily growing number of overseas doctors working in hospitals around the world, and last, but not least, overseas doctors themselves.
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ItemThe epidemiology and impact of viral respiratory infections in pre-school aged children( 2009)BACKGROUND: There are significant gaps in our knowledge of the epidemiology of globally endemic respiratory viruses. Current community research methods are expensive, requiring invasive specimen collection at a home visit by health‐care workers. METHODS: Two cohort studies were conducted to collect better information about the epidemiology and impact of community‐managed respiratory illnesses in pre‐school aged children. The pilot study recruited 121 Melbourne children aged one to four years over winter/spring of 2001. Parents collected daily respiratory symptoms and completed an impact diary, including time seeking health‐care and caring for an ill child, when a pre‐defined acute respiratory illness (ARI) occurred. The Respiratory Virus Study (ReVS) followed 234 Melbourne children less than five years of age for approximately one year from January 2003. A combined nose‐throat swab (NTS), collected by parents when an ARI occurred, was added to pilot study methods. NTS specimens were transported to the Victorian Infectious Diseases Reference Laboratory (VIDRL) for polymerase chain reaction (PCR) to test for influenza A, influenza B, respiratory syncytial virus (RSV), parainfluenza viruses I, II, and III, adenoviruses, and picornaviruses (rhinoviruses, enteroviruses). At the end of the study, available specimens and nucleic acid extracts were shipped on dry ice to the Queensland Paediatric Infectious Diseases (Qpid) Laboratory and tested for human metapneumovirus and human coronavirus NL63. RESULTS: The incidence rate for community‐managed ARI in the pilot study was 0.44 episodes per childmonth (95% CI 0.38 to 0.51) with an average cost per illness of $241 (95% CI $191 to $291). The key cost driver was carer time away from usual activities caring for the ill child, making up 70% of costs. There were 730 ARIs identified in ReVS children for a rate of 0.48 ARIs per child‐month (95% CI 0.45 to 0.52). At least one virus was identified in 401 of 543 ARIs (74%) with a specimen returned, and picornaviruses were identified in 269 ARIs (50%). The total cost of all illnesses with a burden diary returned was $161,454, with over one‐third, $52,597, from illnesses where a picornavirus was identified in isolation. The mean cost of all ARIs was $309 (95% CI $263 to $354), and time spent caring for an ill child was again the key cost driver, responsible for 82% of all costs. The point estimate for the mean cost of influenza A illnesses ($904; 95% CI $89 to $1,719) was three times higher than RSV ($304; 95% CI $194 to $415), the next most expensive illness. Collection by a health‐care worker parent, collector‐reported quality, or presence of a throat swab made no difference to the proportion of specimens positive for any virus. DISCUSSION: Acute respiratory illnesses in community dwelling pre‐school aged children are common and a virus can be detected in 74% of parent‐collected specimens. Use of daily symptom diaries and parent‐collected specimens were effective and efficient study methods, and provide a new model for the future conduct of community‐based epidemiological studies for respiratory pathogens, including efficacy studies for new preventative vaccines and treatments.
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ItemChronic disease services patients in the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management( 2009)This study was a cross-sectional epidemiologic evaluation of the clinical, sociodemographic, lifestyle and hospital utilisation characteristics of patients with diabetes, chronic obstructive pulmonary disease and chronic heart failure. Patients were enrolled in chronic disease management services of the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management (Northern Alliance HARP-CDM Program). The program was established in accordance with the Department of Human Services’ (Victoria, Australia) initiative to intervene against increasing acute hospital demand by patients with chronic disease and complex needs. Amongst others, the Northern Alliance HARP-CDM Program provides services for patients with diabetes, chronic heart failure and chronic obstructive pulmonary disease. Patient cohorts with these three chronic diseases were the focus of this study. The Northern Alliance HARP-CDM Program catchment comprises of a culturally and linguistically diverse (CALD) population in the northern part of metropolitan Melbourne. Patients in this region mainly access acute hospital services at the Northern Hospital. The study sought to explore whether the CDM services enrolled patients whom based on their characteristics, fit the risk profile of the intended HARP-CDM target patient population. The study cohorts demonstrated a CALD make up of above Victorian state averages. The majority (60%) were born overseas, preferred a language other English and were over 60 years old. In contrast to previously published studies, CALD did not demonstrate a significant contribution to disease control, quality of life or level of hospital utilisation. Place of residence for these patients showed clusters within some Local Government Areas. This has implications for service location, access and disease surveillance. Also, it presents opportunities for area targeted health promotion and prevention and overall service location. The majority (77%) of those with chronic heart failure had an abnormal left ventricular ejection fraction. The diabetes cohort was characterised by higher HbA1c (9%) than the target of less than 8%. Similarly the patients had greater than recommended waist circumferences (Males 106cm vs. 94cm; Females 106 vs. 80cm) places them at an increased risk of cardiovascular disease. For those with COPD, 42% had severe pulmonary impairment (FEV%predicted ≤ 40%) while 36% were moderate in the moderate category. There was increased hospital utilisation with increasing age for those with COPD. With the exception of the diabetes cohort, there was no significant evidence as to the role of ethno-cultural factors in the study cohorts’ health, quality of life or level of hospital utilisation. However, ethno-cultural factors may contribute to the complexity of patient management processes and warrants further investigation. Prior to enrolment in the Northern Alliance HARP-CDM Program, patients who could be considered high users of emergency department services made up 20% of those in the diabetes service, 43% in the COPD service and 50% amongst those in the CHF service. Similar figures for hospital admissions ranged from 20% for the diabetes services to 56% for the CHF service cohorts respectively. Although the diabetes service was the biggest of the three the majority of patients in the service had no previous history of acute hospital utilisation. Members of the diabetes service cohort were characterised by hospital utilisation rates lower than the Northern Hospital’s (ED: 34 vs. 72 per 100 patients, Admissions: 33 vs. 68 per 100 patients in the Pre HARP-CDM Period). Patients in the COPD service (ED: 115 Pre and 158 during HARP-CDM) and CHF service (160 Pre and 159 during HARP-CDM) had ED presentation rates per 100patients that were higher than the hospital’s (72 and 69). The rates suggest the first 14 months of the Northern Alliance HARP-CDM Program were associated with increased hospital utilisation by patients enrolled the Northern Alliance HARP-CDM Program. The increments were greater than increases for the Northern Hospital for the same periods. Contrary to the intended goal of reducing acute hospital utilisation, the majority of the clientele did not fit the primary HARP-CDM Program criteria of high acute hospital users. But patients who were enrolled following previous hospital utilisation were well-targeted. However there are several patients who are likely HARP-CDM Program candidates who fall though the gaps between the acute hospital services and the program. It is recommended the program and services increase enrolments and access for the target patient populations. There is a need for early intervention chronic disease management and health promotion. This service would cater for clients who by virtue of having a chronic disease are at risk but are currently not high acute hospital users. Such a service would free up vacancies in the Northern Alliance HARP-CDM Program, thus enabling increased intake and equitable access for the target patient population, especially those who fall though the gaps as referred to earlier. Funding for such a service is available through DHS. In light of strong evidence for exercise rehabilitation and its ability to positively impact patient outcomes, quality of life, survival and hospital utilisation, consideration needs to be given to this as part of the Northern Alliance HARP-CDM Program chronic disease management care model.
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ItemThe Indigenous right of self-determination and 'the state' in the Northern Territory of Australia( 2009)The topic of this thesis is the prolonged denial and eventual recognition of the rights of the Indigenous peoples of Australia following the British assertion of sovereignty. The analysis considers the manner in which the denial and subsequent recognition of Indigenous rights has affected the system of government of the dominant society (the Commonwealth of Australia) in terms of the establishment and evolution of the constitutional framework and associated processes of institutional change in the principles, structures and procedures of the system of government. The primary jurisdiction in which this topic is explored is the Northern Territory of Australia; the primary contexts are the recognition of Indigenous land rights (defined broadly to include associated natural and cultural heritage and resource rights) and the Indigenous right to self government within ‘the state’ (the internationally constituted and recognised polity of the Commonwealth of Australia). The thesis draws on analogous developments in Canada and New Zealand to demonstrate that, while significant progress has been made in the recognition of Indigenous rights since the 1960s, many forms of recognition remain conceptually and procedurally limited. In particular, associated regimes have almost invariably been devised and implemented within a fundamentally monocultural context in which Indigenous rights remain subject to unilateral abrogation or extinguishment by Commonwealth governments. In addition, the legal basis of and requirements for recognition of Indigenous rights according to Commonwealth law result in extremely variable levels of recognition in different areas and contexts, and principles and procedures for the mutual recognition and co-existence of Indigenous and Commonwealth law and systems of government are only partially apparent in the Federal and Northern Territory systems of government. In addition to extending and deepening the recognition of Indigenous rights throughout all relevant institutions of the system of government, to address these deficiencies the thesis argues that constitutional recognition and protection of Indigenous rights and the negotiation of treaties are essential if the Indigenous right of self-determination is to be respected and accommodated by the dominant society.
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ItemThe applied ethics of community involvement in HIV vaccine development( 2009)Since the emergence of HIV/AIDS as a global pandemic in the 1980’s, the focus of the scientific community has been to firstly identify, then treat and ultimately find a cure for, this disease. This has proven to be challenging and far from realistically achievable by the scientific community or the communities affected by this disease. A funding allocation from the National Institutes of Health in the United States came to a consortium in Australia seeking to develop a prime-boost preventative HIV vaccine. The consortium included members of the Australian HIV/AIDS Partnership. This partnership emerged from a particular set of historical contexts and included affected community. The Australian Federation of AIDS Organisations was the affected community representative on the consortium. This thesis sets out the contextual and ethical reasons for this arrangement, and explores how this unusual partnership worked in practice, with a view to identifying its broader implications. HIV vaccine development, and AFAO’s role in that development, is complex and multifaceted. The consortium existed within a particular social context which I explore by describing the social history of HIV in Australia. The search for an HIV vaccine is difficult and complex work requiring significant effort and I describe the challenges involved in such an enterprise. Biomedical research more generally exists in the context of international and national research documents which govern the way in which researchers may conduct human experimental trialling. I discuss these documents and highlight the underlying ethical principles. This research involved 9 interviews with 7 key informants who were members of the consortium. The accounts were analysed following a grounded theory approach, utilising the sensitising concepts outlined in the discussion of the social history of HIV in Australia, the science of HIV vaccine development and the general and specific ethical principles. Following this methodological approach, I identify common themes in the data and discuss the results in greater detail, paying particular attention to the ways this particular social practice plays out in practice and the key ethical considerations arising from the accounts. I also explore the risks, costs and benefits to AFAO of its involvement in the consortium. The overall aim of this research is to understand how practicable, feasible and effective community involvement was in this consortium. Finally, I come to three major conclusions. First, that the consortium is an emerging social practice, which is the intersection of three established social practices; biomedical research, the affected community and the Australian HIV/AIDS Partnership. Using Langford’s criteria for a social practice, I demonstrate the social practice of the consortium was clearly made up of members who were aware of each other’s intentions and beliefs. It was clear from the commencement of the consortium’s project that the consortium was directed at the overall purpose of developing an efficacious preventative prime-boost HIV vaccine. The unique history and tradition of the social practice of the consortium is slightly less clear but what the accounts of the informants demonstrated is that the histories and traditions of the Australian HIV/AIDS Partnership approach and biomedical research, in particular, were a significant influence on most of the consortium members. So much so, that the consortium adopted that unique history and tradition and it was this factor, perhaps above all others, that facilitated AFAO becoming a full partner in the vaccine development enterprise in the first place. Importantly, my research theoretically extends the notion of shared ways of seeing and doing within a social practice. The socialisation aspects are highlighted very strongly within the accounts. Second, AFAO’s involvement was highly concordant with the core principles of the Good Participatory Practice Guidelines for biomedical HIV prevention trials document, and it influenced important protocols within the consortium, but there were also conflict of interest issues for AFAO to manage. Third, the different approaches for community involvement in biomedical HIV prevention trialling (the partnership approach and the Community Advisory Board approach) each has strengths and weaknesses and should be carefully considered in light of the context of the trialling to be conducted. This thesis concludes with a series of recommendations for future biomedical HIV prevention trials.